Common Contracts
1 similar Individual Service Agreement contracts
INDIVIDUAL SERVICE AGREEMENTIndividual Service Agreement • March 24th, 2016
Service 9. Service name 10. Code Initial Revise 11. Unit of Service 12. Units per Visit 13. Frequency of Service 14. Total Units per Week 15. Authorized Cost per Unit 16. Authorized Cost per Week 17. Authorized Cost per Month (weekly cost X 4.33) Provider:●DHS will pay only for those services authorized and provided pursuant to program rules.●This notice confirms arrangements for services made by the Care Manager. You must submit an invoice at the conclusion of service or end of each month of service.●If there is a change in the participant's condition, contact the Care Manager immediately.●Contact the Care Manager if you note errors in the above information or if you have any questions. 18. Specifications: 19. Stop Services - Reason: 20. Resume Services - Date: 21. Other - Specify:
